Taking Antidepressants During Pregnancy

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Deciding whether to start or continue taking an antidepressant if you become pregnant can be a difficult decision. Expectant parents often worry that certain exposures during pregnancy will cause birth defects. Prospective parents may wonder if medications will negatively affect their attempts to conceive.  

Studies have indicated that many medications—including antidepressants—may affect a developing fetus. However, research has also demonstrated that maternal depression can negatively impact fetal development. These effects may even have lasting consequences that stretch into childhood and beyond.

Deciding whether to take antidepressants during pregnancy is not a decision you should make alone. Armed with the facts about each type of antidepressant, you can discuss the pros and cons of your choice with your doctor and mental health care provider. 

Depression During Pregnancy

Depression during pregnancy (also called antepartum or prenatal depression) is one of the most common complications during pregnancy. According to The American College of Obstetricians and Gynecologists (ACOG), 14% to 23% of women experience depression during pregnancy. For reference, around 10% of women in the U.S. have depression.

Pregnancy and Antidepressants

During pregnancy, hormone changes can affect the chemicals in your brain, some of which are directly related to depression. These hormonal shifts can not only influence your mood but also how your body absorbs, distributes, breaks down, and eliminates antidepressant medications, should you choose to take them. 

Up to 8% of pregnant women in the U.S. report being prescribed or using an antidepressant. If you want to continue taking your antidepressant while pregnant, ask your doctor how you can reduce any risks. They may be able to adjust your dosage or start you on another antidepressant.

Antidepressant Use While Breastfeeding

Antidepressants can be passed to your baby through your breast milk. However, the amount that is secreted into breast milk is less than that which crosses the placenta.

The following selective serotonin reuptake inhibitors (SSRIs) are some of the best-studied medications for use during breastfeeding:

  • Paxil (paroxetine)
  • Prozac (fluoxetine)
  • Zoloft (sertraline)

According to multiple studies, the serum antidepressant levels in nursing infants are either low or undetectable, and there have been no reports of short-term adverse effects. For these reasons, they are considered relatively safe for use during breastfeeding.

Prior to 2018, the U.S. Food and Drug Administration (FDA) categorized and labeled all drugs based on research about their safety, including how safe they are to take during pregnancy.

The new system provides information on pregnancy exposure, potential risk, and clinical considerations designed to help physicians use clinical judgment to make decisions that are better based on each woman's needs.

Antidepressants and Birth Effects

The majority of drugs have never been tested on pregnant women, so there is not enough evidence to definitively prove the harms or benefits antidepressants have on a developing fetus. What little research has been done shows that some antidepressants used during pregnancy may increase the risk of birth, while others may not.

The most commonly used antidepressants are SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs). Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs) are also used, though less frequently.

Each class of antidepressant medication carries its own set of risks. If you are pregnant or planning to conceive, it’s important to discuss your individual risk factors with your doctor. It is ideal to discuss a treatment plan in advance of pregnancy rather than making changes once already conceived.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are the most used class of antidepressants during pregnancy. Some of the most common SSRIs prescribed to treat depression during pregnancy include:

Hundreds of studies have looked at SSRI exposure and birth defects. Although findings have been mixed, the overall conclusion is that SSRIs are generally considered safe. But they are not without risk.

According to a 2015 study by the Centers for Disease Control and Prevention (CDC), birth defects occur 2 to 3.5 times more frequently among newborns of women who take Paxil and Prozac. However, because some of the birth defects are rare, this risk is still very low.

Specifically, Paxil use during the first trimester was associated with several birth defects, including heart defects, problems with brain and skull formation (anencephaly), and abdominal wall defects. The study also confirmed links between Prozac use and two types of birth defects—heart wall defects and irregular skull shape (craniosynostosis).

The same 2015 study found no evidence of an association between the use of SSRIs like Celexa (and Zoloft and Lexapro) and birth defects, even though other studies have.

Controversy also exists regarding the association between SSRI use during pregnancy and the risk of persistent pulmonary hypertension of the newborn (PPHN), a rare condition where the babies' lungs don't inflate well. A 2006 study linked SSRI use during late pregnancy with a 6-fold increased risk of PPHN. But many researchers say the linkage is greatly exaggerated.

Up to 30% of SSRI-exposed newborns experience a cluster of symptoms termed the perinatal neonatal adaptation syndrome (PNAS). This syndrome generally presents with symptoms such as jitteriness, irritability, feeding problems, and difficulty breathing. The average time of onset ranges between birth to 3 days of age and lasts for up to 2 weeks.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Serotonin-norepinephrine reuptake inhibitors (SNRIs) block the reuptake of both serotonin and another neurotransmitter called norepinephrine. Common SNRIs include: 

Research shows that using Effexor during early pregnancy may be linked to several birth defects, including heart defects, defects of the brain and spine, cleft lip, and cleft palate.

Tricyclic Antidepressants (TCAs)

Tricyclic antidepressants (TCAs) are the oldest class of antidepressants. They work by blocking neurotransmitters and other receptors in the brain. Though they can be effective as SSRIs in treating depression, they cause more adverse effects/ For this reason, they are not used as first-line treatment and are rarely prescribed for use during pregnancy.

Due to their side effects, they are rarely used during pregnancy, especially not during the first trimester.

The most commonly prescribed TCAs for use during pregnancy include: 

  • Elavil (amitriptyline)   
  • Pamelor (nortriptyline)  
  • Norpramin (desipramine)
  • Tofranil (imipramine) 

There is not enough research to determine whether TCA use during pregnancy has a negative effect on a developing fetus. However, a study published in 2017 indicated that TCAs may be associated with an increased risk of digestive defects as well as eye, ear, face, and neck defects.

Monoamine Oxidase Inhibitors (MAOIs)

Monoamine oxidase inhibitors (MAOIs) work by breaking down neurotransmitters like dopamine and serotonin. Like TCAs, MAOIs class tend to have more side effects than SSRIs and SNRIs. Because of this, and the increased risk of hypertensive crisis, MAOIs are not generally not recommended during pregnancy.

Popular MAOIs include: 

  • Nardil (phenelzine) 
  • Emsam (selegiline) 
  • Marplan (isocarboxazid) 
  • Parnate (tranylcypromine) 

A 2017 case report published in the journal Reproductive Toxicology noted fetal malformations in the two pregnancies of a woman taking high doses of MAOIs. Both pregnancies resulted in fetal abnormalities, one of which was severe enough to result in stillbirth. The second infant was born with severe physical and neurological disabilities.

The authors of the paper speculated that the high dose of MAOIs contributed to outcomes of the pregnancies, but it was not clear if (or how) the medications caused the specific malformations. Additional factors may have contributed, such as the other medications the woman had taken during her pregnancy and the parents' ages (both were over 40). The family also declined to undergo testing to investigate a genetic cause for birth defects.  

Research on the potential risk of Nardil (one of the more commonly prescribed MAOIs) on a developing fetus is limited. The FDA label states that health care providers need to weigh the potential risks of Nardil against the benefits when prescribing the medication for people who are pregnant. This recommendation is consistent with the other MAOI antidepressants as well as medications in other classes.  

Atypical Antidepressants and Antipsychotics 

There are a few other medications that can be prescribed “off-label” to treat depression. Since they don’t neatly fit into one of the other categories, these drugs are referred to as atypical antidepressants/antipsychotics.  

While they are in the same category, the medications work in different ways and are often used to treat mental health conditions other than depression, such as bipolar disorder, schizophrenia, and attention-deficient hyperactivity disorder (ADHD). Some of the medications may also be prescribed to treat chronic pain and irritable bowel syndrome (both of which can co-occur with depression). 

Medications prescribed as atypical antidepressants include: 

  • Wellbutrin (bupropion) 
  • Remeron (mirtazapine) 
  • Oleptro (trazodone)  
  • Trintellix (vortioxetine)
  • Viibryd (vilazodone)

Antipsychotics include:

The drugs within this class may be classified into subcategories based on how they work. For example, Wellbutrin is also classified as a norepinephrine and dopamine reuptake inhibitor (NDRI). 

Risperdal, Seroquel, Latuda, and Zyprexa are considered atypical antipsychotics. These drugs were developed to have fewer side effects than older antipsychotics and work by altering the levels of dopamine in the brain, which can help control symptoms such as hallucinations and paranoia in people with schizophrenia.

Due to the effect on dopamine and other neurotransmitters, atypical antipsychotics may also be helpful for people with severe depression who have not responded to other medications.

Though atypical antipsychotics may be effective, research suggests that using them in combination with antidepressants is associated with an increased risk of death. Before considering antipsychotics try other less risky treatment options, such as augmenting with a second antidepressant.

Researchers are also investigating other medications used to treat depression. For example, the CDC has led many studies on the effect of prescription and over-the-counter medications on pregnancy and fetal development as part of its Treating for Two initiative.

Most classes of antidepressants were evaluated in the research, including popular atypical antidepressants, such as Wellbutrin. A 2010 study indicated that taking Wellbutrin during early pregnancy was associated with an increased risk of fetal heart defects. However, researchers noted that the overall risk for those defects was small and concluded that more research was needed to establish Wellbutrin as a potential cause. Two other larger studies failed to show any link between Wellbutrin and cardiogenic anomalies.

Abilify, another antipsychotic that is sometimes used as an adjunct treatment, has also been the subject of research. A 2018 review of the literature concluded that if someone is taking Abilify before they become pregnant (and the drug has effectively managed their symptoms), health care providers should weigh the potential risks of continuing it against the risks of discontinuation.  

As with other drugs in this class, research about the potential risk of miscarriage, preterm birth, neonatal withdrawal symptoms, birth defects, and the potential for developmental delays is limited and, in some cases, nonexistent.  

Natural Treatments for Depression 

There are also non-prescription or alternative treatments for depression, such as St. John’s wort. Rigorous, formal research does not exist regarding risk of exposure to supplements like St. John’s wart in pregnancy

However, anyone planning to use St. John's wort needs to be aware of potential interactions. For example, taking St. John's wort with medications, supplements, or foods containing 5-hydroxytryptophan (5-HTP), L-tryptophan, or SAMe, can increase your risk for developing serotonin syndrome.

As with medications, ask your doctor about taking a nutritional supplement or herbal remedy if you are pregnant or breastfeeding.

Resources for Research

For information on specific medications or alternative treatments, the Mother-to-Baby exposure database, maintained by the Organization of Teratology Information Specialists (OTIS), can be a helpful resource. The fact sheets created by the non-profit summarize the available research on the use of prescription medications and herbal supplements during pregnancy. 

The Risk of Untreated Depression 

While you will want to consider the risks associated with taking an antidepressant if you are pregnant, it's important to remember that untreated depression also carries risks.

Discontinuing an antidepressant puts you at risk for a relapse of your depression symptoms. The risk may be greater when you are pregnant and right after you give birth.  

Do not discontinue your antidepressant without talking to your doctor or mental health care provider. Unless they direct you to, do not abruptly stop taking your medication. Withdrawing from antidepressants can cause side effects and pregnancy may intensify these symptoms.

Pregnancy was once believed to provide some protection against depression due to shifting hormones, but research has not supported this theory. In fact, the opposite may be true: Some research has shown that depression in either parent can affect the health of a child.  

Many studies have demonstrated that maternal stress during pregnancy can negatively affect fetal development and may influence the later behavior and emotional well-being of the child. 

The physical and emotional stressors of pregnancy can contribute to or worsen feelings of depression. The symptoms of depression can affect how well a person can take care of their needs. This includes everything from practicing overall self-care to pregnancy-specific care such as prenatal appointments.  

People with depression may also be more likely to use substances to cope with their symptoms. The risks associated with drinking alcohol and using illicit drugs during pregnancy are well-established. Substance use during pregnancy can have serious long-term consequences for parents and children.  

Eating well, getting enough sleep, staying physically active, and avoiding drugs and alcohol benefit everyone's well-being, but these considerations are especially important for expectant parents. The demands of pregnancy are felt in the mind as well as the body, so a healthy pregnancy requires taking care of your physical and mental health.  

A Word From Verywell 

There are risks involved with both medication and with untreated depression. If you are trying to decide whether to stop taking your antidepressant during pregnancy, talk to your doctor or therapist. They can help you weigh the risks and benefits of taking antidepressants during pregnancy against the potential consequences associated with letting your depression go untreated.

Being on an antidepressant should not keep you from having a pregnancy. Your doctor can help you find a medication that is safe for your baby and able to control your depressive symptoms. If you decide to stop taking your antidepressant medication while you are pregnant, you need to have a solid support system in place and strategies to help you cope with depression symptoms.

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